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CLO5705 Case Presentation 1

Advance through this case frame by frame and complete the worksheet as you go. The worksheet is posted on Canvas.
by

Daniel Haun

on 28 January 2015

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Transcript of CLO5705 Case Presentation 1

CL05705 Case Presentation 1
Chief Complaint
During a wellness visit, your 65 year-old caucasian female patient reports that she has been feeling tired and has been having problems remembering things.
History
On review of symptoms, she reports difficulty concentrating, fatigue, feeling faint when she stands quickly, and vague gastrointestinal discomfort with some decrease in appetite.
Her family history is negative for neurologic, psychiatric, and autoimmune diseases. Her medications include an antihypertensive as well as an occasional anti-inflammatory drug for episodic headache. Social history reveals a single woman who smokes about one-half pack of cigarettes per day, drinks alcohol only socially, and denies illicit drug use. She has a high school education and, until recently, has worked in the office of a trucking company.
She denies any history of previous trauma, diplopia, dysphagia, vertigo, vision loss, loss of consciousness, back pain, or symptoms of bowel or bladder dysfunction.
She is post-menopausal.
Physical Exam
Vital Signs: T-98.6, HR-76, R-18, B/P-130/80 supine and 95/52 upon standing
Height/Weight: 5'4"/120 lbs.
Oropharynx: clear but pale; Palpebral conjunctivae: pale
Neck: Supple, full active and passive ROM without pain, without audible bruits; no lymphadenopathy; no thyromegaly
Back: No spine tenderness
Lungs: Clear to auscultation
Heart: Regular rate and rhythm; no murmurs
Abdomen: Soft, nontender; no organomegaly
Physical Exam Cont.
She is alert and oriented times three. Her Mini-Mental Status Exam score is 26 out of 30. She misses one point on serial 7s and is able to recall three of three items. There is evidence of bilateral mildly diminished vibration and proprioception. Her reflexes are 3+ throughout with negative Babinski reflex.
The remainder of the neurological exam is normal.
Asssign Pertinent Findings to System(s) and Categories
Which body systems?
Which differential categories (VICTANE)?
Differential Diagnosis
What are your three most likely diagnoses?
Testing Strategy
Which tests would you order and what is the justification?
CBC
CBC findings reveal a mild anemia with slight macrocytosis.
Chem Screen
NORMAL
Serum B12, methylmalonic acid (MMA) and homocysteine (Hcy) levels.
B12 levels borderline normal/low
MMA levels elevated
HCY levels elevated
What is the diagnosis?
NOW WHAT???

Because of your high index of clinical suspicion, you chose to order an anti-intrinsic factor (anti-IF) antibody test to assess for pernicious anemia.

Pernicious anemia was confirmed.
Treatment
You explain that with the diagnosis of pernicious anemia she will have to continue vitamin B12 therapy for the remainder of her life, and you make a note on her chart to assess her compliance at each visit. You also advise her to inform her family of the diagnosis since there is possibly a genetic component.
Oral vitamin B12 1,000 mcg daily Within 2 weeks, she notes less fatigue and normal appetite.
Full transcript